A 77-year-old woman was admitted to hospital. She was frail and
underweight, and had consistently lost weight over the previous
three months. She was charted paracetamol 1g PRN (as required) for
pain relief, with a maximum dose of 4g per day. The woman underwent
bowel surgery without complication. The operative findings
confirmed colon cancer, and she was transferred to a general
surgical ward for recovery.

The woman was being considered for discharge, but fluid began
leaking from her surgical wound. Blood tests indicated that her
LFTs were deranged (abnormal). That night, the on-call house
officer crossed paracetamol off the PRN medication chart and
charted regular paracetamol (1g four times a day). Over the next
few days, nursing staff withheld the woman's prescribed regular
paracetamol owing to her deranged LFTs. The woman's LFTs reached
peak derangement.

The woman was reviewed by a consultant gastroenterologist who
was unable to identify a specific cause for the woman's deranged
LFTs, and noted: "No specific recent drugs to explain LFTs but a
drug-induced hepatitis most likely." The woman's medications were
re-charted by a house officer. The house officer charted
paracetamol, 1g, four times daily as a regular medication and the
prescription was signed off by a ward pharmacist. The house officer
was not aware of any request to stop paracetamol. The medication
chart has "Not for paracetamol" written under the adverse reactions
heading. However, it appears that this was written retrospectively.
Over the next few days, the woman was administered paracetamol as a
regular medication.

The woman began to deteriorate and was transferred to the high
dependency unit. The recorded plan included optimising her fluid
and nutrition status, and searching for the cause of her acute
liver deterioration. The woman was reviewed by a consultant
gastroenterologist who noted that she had acute liver derangement
post-surgery, and ascites. The consultant gastroenterologist
queried whether a drug such as paracetamol had caused her deranged
LFTs. The woman received no further paracetamol. She died a short
time later.

It was held that the woman's prescribed paracetamol dose was too
high. Staff did not think critically and adjust the woman's
paracetamol prescriptions in light of her circumstances. The DHB
had a responsibility to ensure that its staff provide services of
an appropriate standard. It did not provide services to the woman
with reasonable care and skill and, accordingly, it breached Right
4(1).

The nursing staff did well to withhold paracetamol, on occasion,
in response to the woman's deteriorating liver function. However,
there was inadequate communication between nursing and medical
teams regarding the withholding of paracetamol in response to the
woman's deranged LFTs, and inadequate recording of communications.
Furthermore, the woman's medications were re-charted exactly the
same as the previous medication chart, including paracetamol 1g
four times daily, because the house officer was not aware of any
request to stop paracetamol, as the request had not been documented
or communicated, and the prescription was signed off by a ward
pharmacist with no issues raised. Staff did not communicate
effectively to ensure quality and continuity of the services
provided to the woman and, accordingly, the DHB breached Right
4(5).